Limited coverage criteria – rivaroxaban granules

Generic name

rivaroxaban granules for oral suspension

Strength & form

1 mg/mL granules for oral suspension

For the treatment of venous thromboembolic events (VTE) and prevention of VTE recurrence after at least 5 days of initial parenteral anticoagulation treatment if ALL the following criteria are met:

• Special Authority request is submitted by or in consultation with a pediatric hematologist or other pediatric subspecialist with experience managing anticoagulation

AND

• The patient is aged less than 18 years and their body weight is less than 30 kg, or
  • The patient is less than 18 years of age with a body weight of at least 30 kg and is unable to swallow oral rivaroxaban tablets due to disability (includes J-tube or G-tube patients)

Up to patient's 18th birthday